Provider Demographics
NPI:1114405941
Name:KELLY, MELISSA C (PHARMD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-4305
Mailing Address - Country:US
Mailing Address - Phone:928-773-1155
Mailing Address - Fax:
Practice Address - Street 1:2610 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4305
Practice Address - Country:US
Practice Address - Phone:928-773-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist